Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, 795 Willow Road (152 MPD), Menlo Park, CA, USA.
Department of Health Policy, Stanford University School of Medicine, Stanford, CA, USA.
BMC Health Serv Res. 2024 May 8;24(1):601. doi: 10.1186/s12913-024-11063-3.
Previous studies found that documentation of comorbidities differed when Veterans received care within versus outside Veterans Health Administration (VHA). Changes to medical center funding, increased attention to performance reporting, and expansion of Clinical Documentation Improvement programs, however, may have caused coding in VHA to change.
Using repeated cross-sectional data, we compared Elixhauser-van Walraven scores and Medicare Severity Diagnosis Related Group (DRG) severity levels for Veterans' admissions across settings and payers over time, utilizing a linkage of VHA and all-payer discharge data for 2012-2017 in seven US states. To minimize selection bias, we analyzed records for Veterans admitted to both VHA and non-VHA hospitals in the same year. Using generalized linear models, we adjusted for patient and hospital characteristics.
Following adjustment, VHA admissions consistently had the lowest predicted mean comorbidity scores (4.44 (95% CI 4.34-4.55)) and lowest probability of using the most severe DRG (22.1% (95% CI 21.4%-22.8%)). In contrast, Medicare-covered admissions had the highest predicted mean comorbidity score (5.71 (95% CI 5.56-5.85)) and highest probability of using the top DRG (35.3% (95% CI 34.2%-36.4%)).
More effective strategies may be needed to improve VHA documentation, and current risk-adjusted comparisons should account for differences in coding intensity.
先前的研究发现，退伍军人在 Veterans Health Administration（VHA）内部和外部接受治疗时，合并症的记录存在差异。然而，医疗中心资金的变化、对绩效报告的关注度增加以及 Clinical Documentation Improvement 项目的扩展，可能导致 VHA 的编码发生变化。
利用重复的横截面数据，我们比较了退伍军人在不同环境和支付者中的住院 Elixhauser-van Walraven 评分和 Medicare Severity Diagnosis Related Group（DRG）严重程度水平，时间跨度为 2012 年至 2017 年，使用了七个美国州的 VHA 和所有支付者出院数据的链接。为了最小化选择偏差，我们分析了同年同时在 VHA 和非 VHA 医院住院的退伍军人的记录。使用广义线性模型，我们对患者和医院特征进行了调整。
调整后，VHA 入院的预测平均合并症评分始终最低（4.44（95%CI 4.34-4.55）），使用最严重 DRG 的概率最低（22.1%（95%CI 21.4%-22.8%））。相比之下，医疗保险覆盖的入院的预测平均合并症评分最高（5.71（95%CI 5.56-5.85）），使用顶级 DRG 的概率最高（35.3%（95%CI 34.2%-36.4%））。
可能需要更有效的策略来改善 VHA 的记录，并且当前的风险调整比较应该考虑到编码强度的差异。
